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Orthopaedics
Treatment of Charcot Midfoot Deformity by Arthrodesis Using Long Axial Screws
Built from The Surgical Management of the Diabetic Foot and Ankle
What’s inside
14 sections · 96 slides
Overview
- Scope of this topic
The problem in the diabetic foot
- Charcot midfoot deformity
- Effects of diabetes on healing capacity
- Consequences of losing protective sensation
- Additional factors that raise complication risk
- Amputation burden in diabetes
Conservative care and its limits
- Conservative management of the Charcot foot
- Outcomes of early surgical series
- Saltzman study of intensive non-operative treatment
- Simon series of early arthrodesis
- Non-operative versus corrective surgery
The superconstruct principle
- Evolution of fixation techniques
- Definition of a superconstruct
- Four factors defining a superconstruct
- Principle of axial screw fixation
- Advantages of the intraosseous position
- Load sharing behaviour of axial screws
- Beam model of the foot with axial screw reinforcement
- Reading the beam model
Selecting the patient for surgery
- Relative nature of the surgical indications
- Preoperative medical optimisation
- Vascular assessment pathway
- Classification of Charcot midfoot deformity
- Indications for midtarsal osteotomy and arthrodesis
- Ulcer and infection status before internal fixation
- Preoperative management of oedema
Setting up the operation
- Minimum equipment for the axial screw technique
- Patient positioning and tourniquet
- Correction of equinus deformity
- Options for lengthening the posterior calf
Surgical approach
- Planning the incisions
- Exposure of the medial column
- Handling of the posterior tibial tendon
- Exposure of the middle and lateral columns
- Flap thickness and wound healing
- Surgical approach to the medial column and midfoot dislocation
Deforming forces and bone resection
- Tendon forces producing midfoot dislocation
- Tendon pull driving progressive midfoot deformity
- Locating the apex of the deformity
- The two-segment model of correction
- Purposes of bone resection
- Bridging joints without preparing them
- Wedge resection at the apex of the deformity
- Sequence and extent of bone resection
- Protecting the arterial supply during resection
- Bone resection at the level of dislocation
- Sequence of deformity correction
Fixation with long axial screws
- Goal of axial screw fixation
- Antegrade versus retrograde guidewire placement
- Rationale for the retrograde preference
- Author's preferred wire sequence
- Order of column fixation
- Sequential reaming to size the screw
- Tapping and final screw diameter
- Screw diameters by column
- Transition from headed to headless screws
- Medial column screw path
- Middle and lateral column screw paths
- Screw paths across the three columns
- Bone grafting of fusion gaps
- Closure and tendon reattachment
The operation illustrated
- Presentation, imaging and intraoperative realignment
- Definitive fixation and two-year result
Postoperative management
- Immediate postoperative immobilisation
- Follow-up schedule and monitoring
- Progression to weight bearing
- Rehabilitation and footwear
Pitfalls and complications
- Prevention of early wound complications
- Discharge planning and compliance support
- Graded management of wound breakdown
- Communication with the wound centre
- Management of dehiscence and deep infection
- Escalation pathway for wound problems
- Non-union, hardware failure and recurrence
Long-term results
- Design of the long-term follow-up study
- Union outcomes at 52 months
- Hardware failure and functional outcome
- Interpreting the failure numbers
Conclusions
- Place of surgery in Charcot midfoot deformity
- Summary of the long axial screw technique
- References
- References (continued)
- The Surgical Management of the Diabetic Foot and Ankle